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Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or 0 Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the COUNTY OF MARICOPA Instruction sheet which is page 2 of this form. Gro-Well Brands (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 5/1/2018 (date)(2) a warrant/check was issued to the above named person/entity in the amount as stated below. Such warrant/check was either never received or was subsequently inadvertently lost or destroyed and there is no reasonable probability of its being found or presented for payment, or it was not presented for payment within one year after the date of issuance. Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct and the amount shown is due and owing, and the applicant requests that a replacement warrant/check be issued to him/her in the sum of $ 1,361.80 .(3) Signed: Se5'il1 trra (4) Print name: (required) Malissa McGivern Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this day of 20 5e"A-T1111,1-ret NOTARY PUBLIC My commission expires: (seal) Warrant/Check Number 3700025937 (if known) (6) Original Date of Issue 5/1/2018 (if known) (7) Reason for original issue of Warrant/Check (8): El Payroll CLERK, BOARD OF SUPERVISORS MARICOPA COUNTY NI For Services or Goods furnished El Treasurer's refund/payment LII Other: S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc Revised 100518 A.R.S. 11-632 & 11-644 04-23-09 AFFIDAVIT OF UNAUTHORIZED ENDORSEMENT OR ALTERED ITEM State of /fr/ 2-0 IV fri County/Parish ,n ,,,,,.„ert Before me, personally appeared the undersigned affiant ( -Affiant"), who first being duly sworn according to law upon the Affiant's oath did depose and say: That for each item listed below as a forged endorsement, the item was not signed or endorsed, as appropriate, by Affiant or by an authorized agent of Affiant and was done without Affiant's knowledge or consent; and that for each item listed below as an altered item, the item was altered without the Affiant's knowledge or consent. Affiant did not receive any benefit from the item(s) and has not ratified the signature, endorsement, or alteration on any of the items. An original or certified copy of each item listed below is attached hereto. Affiant will testify to the truth of the foregoing, file police reports and press charges as reasonably requested by the Bank, and otherwise cooperate in any legal proceedings which may be instituted in connection with this matter. Affiant understands that the bank may deny all claims, and will be entitled to recover from Affiant any claims previously paid, if Affiant fails to comply with these requirements. Affiant understands that the bank may cause the arrest of a person for the unauthorized signature or alteration on the items in reliance on the representation made by Affiant. Affiant will indemnify and hold harmless the bank from any liability arising out of such arrest in the event that the representation made by the Affiant should prove to be false. Affiant is aware that (i) this Affidavit is being provided to the Bank to obtain payment of the items, (ii) the Bank will rely on this Affidavit in making such payment and (iii) a false statement herein may be a violation Of the law. Affidavit represents that all responses contained in this Affidavit are true and complete. Type* Check Number Dollar Amount Payee Date of check Signed by: FE 3700025937 $1,361.80 Gro-Well Brands 5/1/2018 Steve Watson COPY OF CHECK MUST BE ATTACHED TO THIS FORM. ONLY ONE AFFIDAVIT PER CHECK. *Types of Forgery: FE Forged Endorsement (signature on back of check is unauthorized). Back of check is not endorsed by the payee. ME Missing Endorsement (non-receipt of funds) there is no endorsement on back of check. IE Improper Endorsement, (endorsed not as drawn,) endorsement on back does not match the payee line on front of check. Al Altered Item(s) (the check contains an authorized signature, but the payee or amount was changed after the check was createdl If THE MAKERS'S SIGNATURE HAS BEEN ALTERED PLEASE CALL 866-564-2262 OPT 3 BEFORE FILLING OUT AFFIDAVIT **FOR ITEM THAT HAS AN ALTERED PAYEE AND/OR DOLLAR AMOUNT, PLEASE COMPLETE BELOW: Check Number Original Payee Payee as Altered Original Amount Amount as Altered Affiant's Mailing Address Gro-Well Brands Dept LA 24382 Print Name (Business Name, if applicable) Pasadena, CA 91185 k/2 Re,-(2 Job Title (if business account) Affiant's Phone Number Account Number SUBSCRIBED AND SWORN before me on (ic,f 51 , .201 . tA/ —;14-e-k-So SEAL Print Name (Notary Public) Return the completed notarized form to: Notary LINDA Public JACKSON - Arizona JPMorgan Chase Bank, N.A. Maricopa County 340 South Cleveland Ave Floor 3 My Comm. Commission Expires # 549076 Jul 30, 2022 Westerville, OH 43081-0273 ,J•41r9.•II I Phone# 800-578-6957 opt 1 Maricopa Education Service Agency 4041 N Central Ave. Suite 200 Phoenix, AZ 85012 To whom it may concern: Malissa McGivern runs the A/R Department for Gro-Well Brands. She is authorized to act on behalf of the company. Thank you, GROWELL BRANDS 420 East Southern Ave Tempe, Arizona 85282 RECEIVED NOV 2 6 2018 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS Oa_ f